- Email: [email protected]
Role of Emerging Technologies in Geriatric Pain Management
R o l e o f Em e r g i n g Tec h n o l o g i e s i n G e r i a t r i c P a i n M an ag emen t Rachael Elizabeth Docking,
PhD, MA (Hons)
KEYWORDS Older adults Technology Pain management Pain assessment Apps mHealth KEY POINTS Emerging technologies can help to create innovative methods to assess and manage in older adults. Although there is some evidence for the efficacy of the technologies, existing studies rarely focus on older populations. There are still several changes required to ensure the secure use of technology in clinical settings; for example, acute care, long-term care, urgent care, and primary care. Most pain applications that have been developed so far have had almost no input from health care professionals or end users. Future technologies should be developed with appropriate clinical and end user partners to maximize their relevance.
INTRODUCTION
The use of technology has become a key part of life as the availability of tablets and smartphones has continued to increase. Innovation has moved to focus on emerging new technologies and their ability to improve health and wellbeing. In particular, applications (apps) can be used by consumers and patients as part of homecare and selfcare, thus potentially providing cost savings to health systems.1 As pointed out by the recent report from the IMS Institute for Healthcare Informatics, although there is increasing enthusiasm for the use of technology in health care, the use of apps still remains a novelty. The past century has seen an increase in life expectancy2 and, for the first time, people 60 years and older outnumber those younger than 16 years.3 With increasing age comes the increase of diseases of old age such as dementia, arthritis, and cancer. Dementia affects approximately 35.6 million persons globally4 and it has been estimated
Faculty of Health, Social Care and Education, Anglia Ruskin University, London, 4th Floor William Harvey Building, Bishop Hall Lane, Chelmsford Essex, CM1 1SQ, UK E-mail address: [email protected] Clin Geriatr Med - (2016) -–http://dx.doi.org/10.1016/j.cger.2016.06.011
geriatric.theclinics.com
0749-0690/16/Crown Copyright ª 2016 Published by Elsevier Inc. All rights reserved.
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Docking
that the prevalence of dementia will double every 20 years (Ferri and colleagues,5 2005). There is also evidence that the prevalence of pain increases with age, particularly disabling pain or pain sufficient to interfere with day-to-day living.6–8 Dionne and colleagues6 reviewed epidemiologic studies that examined back pain prevalence by age and found that although older people experience a decrease in nondisabling back pain they experience an increased prevalence of disabling back pain. Docking and colleagues8 found, in a United Kingdom (UK) population, that although nondisabling back pain plateaued in older age, disabling back pain continued to increase in the oldest old. Also, Thomas and colleagues7 reported that the onset of pain that interferes with everyday life continues to increase with age. This increase in pain in older adults, along with the increasing use of technology, presents a huge opportunity for health care staff and researchers to harness advances in technology to develop new ways of assessing pain and delivering education, support, and behavior change interventions for the management of pain in later life.9 Due to the increased use of technology within health care, the World Health Organization (WHO) has coined the term mobile health (mHealth), which refers to medical and public health practice supported by mobile devices.10 Certain patient groups have greater challenges and barriers to accessing care (eg, older adults) due to problems such as geographic distance from health care centers, obtaining transportation services, and increased mobility difficulties. Therefore, the use of technology-based approaches for older people with various pain conditions may lead to significant cost savings in intervention delivery but also improved quality of life and feelings of control among patients. The demand for support for pain management and assessment in older adults is set to grow rapidly as the population continues to age. There is a need for sufficient evidence of the benefit technology can offer regarding improved patient outcomes and reduced health care costs. Additionally, those in the health and care services will need to embrace more technology-enabled products, services, and systems to allow for the successful and efficient management of pain in the older population. This article provides a brief overview of the challenges and opportunities that technology can offer geriatric pain management and reviews emerging evidence to demonstrate the role that technology can play in improving and advancing how to not only assess but manage pain in older adults.
EVIDENCE REGARDING THE USE OF TECHNOLOGY FOR PAIN CARE
The last few years have seen substantial progress in ways to make the management of pain as accurate, reliable, and convenient as possible, including technology-assisted self-management interventions, electronic pain diaries, clinical dashboards, and interventions delivered using Internet and mobile apps. The following section discusses some of the evidence regarding the use of technology for assessing and managing pain among older adults. Pain Assessment
Currently, there is limited research to inform the assessment and management of pain in those 65 years of age and older, particularly those with dementia. Evidence suggests that this group may not receive adequate assessment of their pain11 and pain that is assessed is often undertreated or poorly managed.12–14 One innovative example of how technology could help to improve the assessment of pain in older adults with dementia is described in the following section.
Emerging Technologies in Geriatric Pain Management
Evaluation of the iPhone Pain Assessment Application for People with Dementia
Given the aging of the population, greater numbers of older adults are living in their own homes and will require the use of emergency (eg, paramedic) services. Pain management in the paramedic setting is increasingly important in the UK ambulance services where 80% of patients present with pain-related complaints (in other countries as well).15,16 Paramedics report barriers to providing adequate pain relief such as concerns about patient accuracy in evaluating their own pain and the effect of analgesia interfering with clinical assessments. Furthermore, paramedics identified that many patients with dementia or cognitive impairments have problems communicating their pain and, as such, pain may be ignored, overlooked, or mistaken for challenging behavior.15 Currently, national clinical guidelines for paramedics recommend the Verbal Rating Score and Wong-Baker FACES Scale to assess pain. However, these scales do not account for patients who have difficulty communicating. Considering this, researchers at the University of Greenwich collaborated with the Computing and Mathematical Sciences department to develop an iPhone pain assessment app (Fig. 1). This app was evaluated in the South London Ambulance Service (LAS) National Health Service (NHS) Trust and the South East Coast Ambulance (SECAmb) Service NHS Foundation Trust to explore the feasibility of using it to assess pain among adults with dementia in the paramedic setting and to explore paramedic students’ ideas on how the app could be modified or improved.17 Following this, recommended changes put forward by the paramedic students were presented to an expert panel of paramedics who selected those most relevant for future implementation of the app.
Fig. 1. iPhone pain assessment app screenshots. (Courtesy of University of Greenwich, London, United Kingdom; with permission.)
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The results indicated that the iPhone pain assessment tool for older adults with cognitive impairment could be a useful tool in the prehospital setting and, potentially, other populations with communication difficulties. Evidence suggests that one of the most common reasons for dialing 999 (911 in the US) is because an individual is experiencing pain.18 Providing access to a tool in the paramedic setting that has been specifically developed to help identify and assess pain in a user-friendly format may well result in improvements in pain management and, subsequently, improved quality of life for the adult with dementia. The most common concerns raised, however, were the use of technology in the clinical setting and how appropriate it is to use electronic devices while working with a patient, as well as the lack of adequate support for paramedic staff to allow them the opportunity to use app-based assessment methods in practice. Most participants did not think that use of an iPad, or similar electronic device, was currently possible in the clinical setting. The development of apps such as this provides new insights into innovative methods for pain assessment for older adults, particularly those with cognitive impairment. The benefits of implementing such a tool are potentially wide reaching, improving health care professionals’ knowledge and confidence in pain assessment for older adults, thereby improving pain management. In addition, there is huge potential for wider application of the tool along with national implementation in the paramedic emergency service system. Other possible clinical situations in which the app could be used include emergency departments, acute care wards, and nursing homes. There is also the potential for use within an informal care setting. Pain Management
A recent report from the Institute of Medicine recommended the promotion of selfmanagement of pain through the use of technology.19 The following section describes some recent technology-related pain management techniques that have been reviewed in the literature. Pain Management Applications
With an increasing use of smartphones, it is becoming increasingly popular to download apps. A recent review of pain apps20 found 111 available apps across the major mobile platforms. The investigators included apps if they focused on pain education, pain management, or pain relief, and were not specifically aimed at health care professionals. There was limited health care professional involvement in the development of the apps (86% reported no involvement). All pain apps offered the promise of pain relief; however, few contained any evidence-based pain management features. Palermo and Jamison9 published a special series providing a contemporary overview of technology-assisted self-management interventions for chronic pain in adults. They were examining patient-focused smartphone apps for pain management. Palermo and Jamison9 rated the functionality of 279 apps, most of these provided self-monitoring or pain education; however, few implemented more than one pain self-management function. Further, most were designed without any input from health care professionals. The investigators concluded that it is essential for pain apps to include input from scientists to ensure they are robust and valid. Palermo and Jamison9 thought that the topic of technology and pain self-management is timely and they encouraged future research in this area. Potential benefits include improved pain management for the individual but also a significant reduction in the economic cost of chronic pain. Of note, the evidence summarized in the review
Emerging Technologies in Geriatric Pain Management
focused on children, adolescents, and adults; none of the reviewed studies focused on older adults. A recent review by the IMS Institute for Healthcare Informatics1 reported on a whole range of health care apps, some of which related to pain management in the adult population, but none specific to older adults. For example, the WebMD pain coach is an app that provides a holistic approach to balancing lifestyle with chronic pain conditions. WebMD is designed as a mobile companion, allowing patients to be in control of their lifestyle choices and to review personal patterns to understand triggers, set goals, and easily share progress with health care staff. The only other pain-related app reviewed within this report was Zimmer Arthritis 411, which is a patient education resource for people who suffer from arthritis. It is designed to be used either by the patient or in conjunction with the clinician during consultation. These have not been further reviewed or validated so it is not possible to report on their effectiveness in improving pain management in older adults. Clinical Dashboards
A clinical dashboard is a tool that aims to provide clinicians with relevant information. They provide clinicians with quick and easy access to health care data that are being captured locally, along with information to help them make clinical decisions, such as best practice advice. Anderson and colleagues21 evaluated the impact of a clinical dashboard for opioid analgesic management on opioid prescribing and adherence to opioid practice guidelines in primary care. They evaluated electronic health record data from patients receiving chronic opioid therapy. After implementation of the dashboard, there was an increased adherence to certain opioid practice guidelines, including rate of urine drug testing, signing an opioid treatment agreement, conducting assessment of pain-related functional status, and having at least one visit with a behavioral health provider. There was also some evidence of a decline in chronic opioid therapy. Internet-Based Interventions
A recent review by Bender and colleagues22 examined articles published between 1990 and 2010 that evaluated evidence for Internet-based interventions for individuals with chronic pain. The review found that the interventions consisted mainly of (1) cognitive behavioral therapy (CBT), (2) moderated peer-support programs, or (3) clinical support interventions. The Internet CBT interventions were predominantly structured, self-administered programs that provided minimal support from health care staff. Peer support programs were those that allowed people with similar symptoms to exchange experiences and use a network of support. Whereas clinical support interventions were those that, for example, allowed the patient to access educational Web sites to prepare for doctor visits and provide self-management advice afterward. Most CBT interventions for pain management demonstrated an improvement in pain, improved function, and decreased costs compared with standard care. However, the effects on depression and anxiety were less consistent, which may be due to the lack of person contact. The online peer-support network evidence showed a significant reduction in the prevalence of pain and anxiety, and reduced loneliness and withdrawn behavior. Finally, clinical support interventions helped to significantly reduce pain and improved patient’s knowledge. Although this evidence was interesting, there was no specific focus on older adults, with most of the evidence focusing on children and young adults.
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Text Messaging
There is currently limited evidence regarding the effectiveness of text messaging for pain management and nothing specific to older adults. Recent evidence published in 201523 examined the preliminary effectiveness of a text message–based social support intervention for adults that aimed to reduce daily pain and pain interference, improve affect and perceptions of social support in patients with chronic noncancer pain, and explore the feasibility of a novel mobile app to track perceptions of pain and pain interference. Results found modest reductions in pain in those who received the text messages. Although this study was not specific to older adults, it did include older adults within the sample and provides some support for the feasibility of such methods in improving patients’ daily experience of pain. A recent review summarizes existing evidence regarding the compliance, feasibility, user-friendliness, reliability, and validity of text messaging in pain patients.10 Text messages could be an inexpensive way for communication between patients and health care professionals for chronic pain management. Further, this method could be easily integrated into mobiles or smartphones, which most of the population own. CHALLENGES WITH TECHNOLOGY Challenges for Health Care Staff Using Technology for Pain Management
The recent evaluation of the iPhone pain assessment app by Docking and colleagues,17 previously described, uncovered a range of challenges that health care professionals might face when using technology in the clinical setting. These challenges are detailed briefly in the following section. Appropriateness of Technology in the Clinical Setting
There are questions around the appropriateness of using technology within the clinical setting and the lack of adequate support for clinical staff to allow them the opportunity to use app-based methods in practice. In the evaluation of the iPhone pain app, most participants did not think that use of an electronic device was currently feasible in the clinical setting. This was predominantly due to their worries over perceptions of patients while using such devices. Suggestions to address this barrier include using current electronic systems in which the app could be incorporated, and changing the way in which clinicians work and record data to a more electronic-based method. All participants were in agreement that as the technology age advances there will be an increased need for technology in the clinical setting that will bring with it greater acceptance and understanding from patients of the benefit such methods can bring. Cost
There is a clear need for a cost analysis regarding the effectiveness of technologybased interventions. Taking into account the development and maintenance costs, savings across the health care system must be demonstrated and there is currently a lack of cost-analysis studies to show this outcome. Health care systems have recently made a move toward the use of electronic health records. Therefore, it might be feasible to allow for an integration of mobile appgenerated data into these systems, which could potentially reduce costs. However, this will require a huge amount of collaboration between stakeholders to allow for a smooth transition into a new technology-led health care system.
Emerging Technologies in Geriatric Pain Management
Infrastructure
The infrastructure required for a move toward technology does not currently exist from both a health care and a patient perspective. There are serious concerns around data privacy and security when using such methods. It is therefore essential that it is clear how data within apps will be used, ensuring patient consent is provided, and that the information held is secure, particularly if there is integration with electronic health records and health-related apps. With the potential for confidential patient information to be passed between systems, it is essential this is done in a secure manner and, currently, there is no infrastructure to support that. Technical Support
Current apps are not yet compatible with hospital-based electronic medical records and, as a result, there will be issues with data transfer. It is unclear who would have the responsibility to provide technical support for apps: medical informaticians, app providers, or both. Although apps should save time and money and reduce face-toface visits, there could be additional costs if technical problems occur and regularly persist. Hygiene
When using apps in the clinical setting, it is essential to be aware of the spread of infections. If tools, such as tablets, are used for pain assessment and management in a clinic, it is important that these are given suitable covers that can be regularly cleaned if they are used across patients. Challenges for Patients Using Technology for Pain Management
There is currently limited evidence to help patients understand the apps that are currently available and which apps might be most useful in assisting patients with the task of self-managing pain. This is a particular challenge for older adults who may have limited online experience and be less able to research the evidence base for health-related apps. Older adults may also not feel comfortable using certain software, and there may be challenges around reading, language, or cognitive skills.9 In the UK, the NHS developed and launched a library of NHS-reviewed apps (in 2013) aimed at empowering people to manage their own health. The NHS reviewed apps available on the market to provide consumers with evidence of which apps were clinically safe and reliable. With increasing health care costs and limited funding, the library was designed to encourage patients to be active participants in how their health is managed. Although this Web site was a step in the right direction, it did not answer all the concerns around the use of apps in health care, particularly in relation to security of patient information. The library has now been closed after coming to the end of a period of testing. However, there are plans to conduct an evaluation, glean any lessons that can be learned from this initiative, and help to inform the development of something similar in the future. Concerns over the safety and security of patient information, however, have been raised. A recent study24 found that many of the apps that were recommended failed to provide adequate protection of patient data. The investigators reported that out of 35 apps in the library that sent identifying information over the Internet, 23 did so without encryption. Therefore, although such a library would be welcomed, steps need to be taken to address these concerns and make changes where needed.
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SUMMARY
Technology has the potential to play an instrumental role in serving patients by making health care more affordable, accessible, and available. Although the future role of technology in the management of pain in the older population is promising, there are clearly current challenges that need to be addressed before technology can be fully integrated into the health care system. mHealth might provide us with the opportunity to collect clinical, patient lifestyle, and behavior data, which could improve communication between the patient and the health care provider, and may also aid in the assessment of pain within the clinical setting. However, few technologies currently exist to meet the needs of older people with chronic pain. In addition, there is limited evidence that the technology leads to improved patient outcomes or reduces use of health care services.10 Further work is needed to look into the impact of apps on hospital and clinic visits before additional money is spent developing and testing new innovations, as well as to clarify whether technology can ultimately contribute to a reduction in the burden of chronic pain. With further evidence and input from health care professionals and patients on what they actually need from emerging technologies, it might be possible to take advantage of what the technology age has to offer, to develop and use tools that can potentially improve the quality of life for older adults living with pain, and to ensure they can remain living independently and within their own homes for as long as possible. Author’s key recommendations With currently limited technologies that meet the needs of older people with chronic pain and questions around improved outcomes from technology, there is currently not enough evidence to recommend that health care professionals make use of current pain apps. However, as technology develops within this field, health care professionals should remain up to date on evidence as it emerges. The recently closed NHS library of NHS-reviewed apps is potentially going to reopen following its initial pilot testing phase. If this does happen, this would be an ideal place for health care professionals to start if interested in using apps within their practice, to identify the most useful and well-evaluated apps available for pain management. REFERENCES
1. Aitken M, Gauntlett C. Patient apps for improved healthcare: from novelty to mainstream. Parsippany (NJ): IMS Institute for Healthcare Informatics; 2013. 2. Tse MMY, Pun SPY, Benzie IFF. Pain relief strategies used by older people with chronic pain: an exploratory survey for planning patient-centred intervention. J Clin Nurs 2005;14(3):315–20. 3. Office of National Statistics. 2010. Available at: http://www.statistics.gov.uk/ default.asp. Accessed December 4, 2015. 4. World Health Organisation. Dementia: a public health priority. United Kingdom: Alzheimer’s Disease International; 2012. Available at: http://www.who.int/ mental_health/publications/dementia_report_2012/en/. Accessed July 8, 2015. 5. Ferri CP, Prince M, Brayne C, et al. Global prevalence of dementia: a Delphi consensus study. Lancet 2005;366(9503):2112–7. 6. Dionne CE, Dunn KM, Croft PR. Does back pain prevalence really decrease with increasing age? A systematic review. Age Ageing 2005;35(3):229–34.
Emerging Technologies in Geriatric Pain Management
7. Thomas E, Mottram S, Peat G, et al. The effect of age on the onset of pain interference in a general population of older adults: prospective findings from the North Staffordshire Osteoarthritis Project (NorStOP). Pain 2007;129:21–7. 8. Docking RE, Fleming J, Brayne C, et al, Cambridge City over-75s Cohort Study Collaboration. Epidemiology of back pain in older adults: prevalence and risk factors for back pain onset. Rheumatology (Oxford) 2011;50(9):1645–53. 9. Palermo TM, Jamison RN. Innovative delivery of pain management interventions: current trends and future progress. Clin J Pain 2015;31(6):467–9. 10. Vardeh D, Edwards RR, Jamison RN, et al. There’s an app for that: mobile technology is a new advantage in managing chronic pain. ISAP Pain Clinical Updates 2013;21(6):1–7. 11. Closs SJ, Barr B, Briggs M, et al. A comparison of five pain assessment scales for nursing home residents with varying degrees of cognitive impairment. J Pain Symptom Manage 2004;27(3):196–205. 12. Helme RD, Gibson SJ. Pain in older people. In: Crombie IK, Croft PR, Linton SJ, et al, editors. Epidemiology of pain. Seattle (WA): IASP Press; 1999. p. 103–12. 13. Scherder E, Oosterman J, Swaab D, et al. Recent developments in pain in dementia. Br Med J 2005;330(7489):461–4. 14. Williams E, Sutton S. Elderly fallers referrals: update. United Kingdom: London Ambulance Service; 2012. Clin Update 28. Available at: http://www. londonambulance.nhs.uk/health_professionals/gp_information/idoc.ashx?docid5 c5ec9929-66a8-41a1-8e9a-28d08fe25278&version5-1. Accessed December 4, 2015. 15. Harvey C. Is there scope for an observational pain scoring tool in paramedic practice? J Paramedic Pract 2014;6(2):84–8. 16. Bonica JJ, Loeser JJ, Chapman CR, et al. The management of pain. Philadelphia: Lea and Febiger; 1990. 17. Docking RE, Lane M, Schofield PA. Developing an iPhone APP for the assessment of pain in older adults with dementia. Presented at the 7th International Congress of Pain in Dementia, Bergen, Norway, April 24–25, 2015. 18. McLean SA, Maio RF, Domeier RM. The epidemiology of pain in the prehospital setting. Prehosp Emerg Care 2002;6(4):402–5. 19. Simon LS. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Journal of Pain & Palliative Care Pharmacotherapy 2012;26(2):197–8. 20. Rosser BA, Eccleston C. Smartphone applications for pain management. J Telemed Telecare 2011;17(6):308–12. 21. Anderson D, Zlateva I, Khatri K, et al. Using health information technology to improve adherence to opioid prescribing guidelines in primary care. Clin J Pain 2015;31(6):573. 22. Bender JL, Radhakrishnan A, Diorio C, et al. Can pain be managed through the Internet? A systematic review of randomized controlled trials. Pain 2011;152(8): 1740–50. 23. Guillory J, Chang P, Henderson CR Jr, et al. Piloting a text message–based social support intervention for patients with chronic pain: establishing feasibility and preliminary efficacy. Clin J Pain 2015;31(6):548–56. 24. Huckvale K, Prieto JT, Tilney M, et al. Unaddressed privacy risks in accredited health and wellness apps: a cross-sectional systematic assessment. BMC Med 2015;13(1):214.
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PhD, MA (Hons)
KEYWORDS Older adults Technology Pain management Pain assessment Apps mHealth KEY POINTS Emerging technologies can help to create innovative methods to assess and manage in older adults. Although there is some evidence for the efficacy of the technologies, existing studies rarely focus on older populations. There are still several changes required to ensure the secure use of technology in clinical settings; for example, acute care, long-term care, urgent care, and primary care. Most pain applications that have been developed so far have had almost no input from health care professionals or end users. Future technologies should be developed with appropriate clinical and end user partners to maximize their relevance.
INTRODUCTION
The use of technology has become a key part of life as the availability of tablets and smartphones has continued to increase. Innovation has moved to focus on emerging new technologies and their ability to improve health and wellbeing. In particular, applications (apps) can be used by consumers and patients as part of homecare and selfcare, thus potentially providing cost savings to health systems.1 As pointed out by the recent report from the IMS Institute for Healthcare Informatics, although there is increasing enthusiasm for the use of technology in health care, the use of apps still remains a novelty. The past century has seen an increase in life expectancy2 and, for the first time, people 60 years and older outnumber those younger than 16 years.3 With increasing age comes the increase of diseases of old age such as dementia, arthritis, and cancer. Dementia affects approximately 35.6 million persons globally4 and it has been estimated
Faculty of Health, Social Care and Education, Anglia Ruskin University, London, 4th Floor William Harvey Building, Bishop Hall Lane, Chelmsford Essex, CM1 1SQ, UK E-mail address: [email protected] Clin Geriatr Med - (2016) -–http://dx.doi.org/10.1016/j.cger.2016.06.011
geriatric.theclinics.com
0749-0690/16/Crown Copyright ª 2016 Published by Elsevier Inc. All rights reserved.
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Docking
that the prevalence of dementia will double every 20 years (Ferri and colleagues,5 2005). There is also evidence that the prevalence of pain increases with age, particularly disabling pain or pain sufficient to interfere with day-to-day living.6–8 Dionne and colleagues6 reviewed epidemiologic studies that examined back pain prevalence by age and found that although older people experience a decrease in nondisabling back pain they experience an increased prevalence of disabling back pain. Docking and colleagues8 found, in a United Kingdom (UK) population, that although nondisabling back pain plateaued in older age, disabling back pain continued to increase in the oldest old. Also, Thomas and colleagues7 reported that the onset of pain that interferes with everyday life continues to increase with age. This increase in pain in older adults, along with the increasing use of technology, presents a huge opportunity for health care staff and researchers to harness advances in technology to develop new ways of assessing pain and delivering education, support, and behavior change interventions for the management of pain in later life.9 Due to the increased use of technology within health care, the World Health Organization (WHO) has coined the term mobile health (mHealth), which refers to medical and public health practice supported by mobile devices.10 Certain patient groups have greater challenges and barriers to accessing care (eg, older adults) due to problems such as geographic distance from health care centers, obtaining transportation services, and increased mobility difficulties. Therefore, the use of technology-based approaches for older people with various pain conditions may lead to significant cost savings in intervention delivery but also improved quality of life and feelings of control among patients. The demand for support for pain management and assessment in older adults is set to grow rapidly as the population continues to age. There is a need for sufficient evidence of the benefit technology can offer regarding improved patient outcomes and reduced health care costs. Additionally, those in the health and care services will need to embrace more technology-enabled products, services, and systems to allow for the successful and efficient management of pain in the older population. This article provides a brief overview of the challenges and opportunities that technology can offer geriatric pain management and reviews emerging evidence to demonstrate the role that technology can play in improving and advancing how to not only assess but manage pain in older adults.
EVIDENCE REGARDING THE USE OF TECHNOLOGY FOR PAIN CARE
The last few years have seen substantial progress in ways to make the management of pain as accurate, reliable, and convenient as possible, including technology-assisted self-management interventions, electronic pain diaries, clinical dashboards, and interventions delivered using Internet and mobile apps. The following section discusses some of the evidence regarding the use of technology for assessing and managing pain among older adults. Pain Assessment
Currently, there is limited research to inform the assessment and management of pain in those 65 years of age and older, particularly those with dementia. Evidence suggests that this group may not receive adequate assessment of their pain11 and pain that is assessed is often undertreated or poorly managed.12–14 One innovative example of how technology could help to improve the assessment of pain in older adults with dementia is described in the following section.
Emerging Technologies in Geriatric Pain Management
Evaluation of the iPhone Pain Assessment Application for People with Dementia
Given the aging of the population, greater numbers of older adults are living in their own homes and will require the use of emergency (eg, paramedic) services. Pain management in the paramedic setting is increasingly important in the UK ambulance services where 80% of patients present with pain-related complaints (in other countries as well).15,16 Paramedics report barriers to providing adequate pain relief such as concerns about patient accuracy in evaluating their own pain and the effect of analgesia interfering with clinical assessments. Furthermore, paramedics identified that many patients with dementia or cognitive impairments have problems communicating their pain and, as such, pain may be ignored, overlooked, or mistaken for challenging behavior.15 Currently, national clinical guidelines for paramedics recommend the Verbal Rating Score and Wong-Baker FACES Scale to assess pain. However, these scales do not account for patients who have difficulty communicating. Considering this, researchers at the University of Greenwich collaborated with the Computing and Mathematical Sciences department to develop an iPhone pain assessment app (Fig. 1). This app was evaluated in the South London Ambulance Service (LAS) National Health Service (NHS) Trust and the South East Coast Ambulance (SECAmb) Service NHS Foundation Trust to explore the feasibility of using it to assess pain among adults with dementia in the paramedic setting and to explore paramedic students’ ideas on how the app could be modified or improved.17 Following this, recommended changes put forward by the paramedic students were presented to an expert panel of paramedics who selected those most relevant for future implementation of the app.
Fig. 1. iPhone pain assessment app screenshots. (Courtesy of University of Greenwich, London, United Kingdom; with permission.)
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The results indicated that the iPhone pain assessment tool for older adults with cognitive impairment could be a useful tool in the prehospital setting and, potentially, other populations with communication difficulties. Evidence suggests that one of the most common reasons for dialing 999 (911 in the US) is because an individual is experiencing pain.18 Providing access to a tool in the paramedic setting that has been specifically developed to help identify and assess pain in a user-friendly format may well result in improvements in pain management and, subsequently, improved quality of life for the adult with dementia. The most common concerns raised, however, were the use of technology in the clinical setting and how appropriate it is to use electronic devices while working with a patient, as well as the lack of adequate support for paramedic staff to allow them the opportunity to use app-based assessment methods in practice. Most participants did not think that use of an iPad, or similar electronic device, was currently possible in the clinical setting. The development of apps such as this provides new insights into innovative methods for pain assessment for older adults, particularly those with cognitive impairment. The benefits of implementing such a tool are potentially wide reaching, improving health care professionals’ knowledge and confidence in pain assessment for older adults, thereby improving pain management. In addition, there is huge potential for wider application of the tool along with national implementation in the paramedic emergency service system. Other possible clinical situations in which the app could be used include emergency departments, acute care wards, and nursing homes. There is also the potential for use within an informal care setting. Pain Management
A recent report from the Institute of Medicine recommended the promotion of selfmanagement of pain through the use of technology.19 The following section describes some recent technology-related pain management techniques that have been reviewed in the literature. Pain Management Applications
With an increasing use of smartphones, it is becoming increasingly popular to download apps. A recent review of pain apps20 found 111 available apps across the major mobile platforms. The investigators included apps if they focused on pain education, pain management, or pain relief, and were not specifically aimed at health care professionals. There was limited health care professional involvement in the development of the apps (86% reported no involvement). All pain apps offered the promise of pain relief; however, few contained any evidence-based pain management features. Palermo and Jamison9 published a special series providing a contemporary overview of technology-assisted self-management interventions for chronic pain in adults. They were examining patient-focused smartphone apps for pain management. Palermo and Jamison9 rated the functionality of 279 apps, most of these provided self-monitoring or pain education; however, few implemented more than one pain self-management function. Further, most were designed without any input from health care professionals. The investigators concluded that it is essential for pain apps to include input from scientists to ensure they are robust and valid. Palermo and Jamison9 thought that the topic of technology and pain self-management is timely and they encouraged future research in this area. Potential benefits include improved pain management for the individual but also a significant reduction in the economic cost of chronic pain. Of note, the evidence summarized in the review
Emerging Technologies in Geriatric Pain Management
focused on children, adolescents, and adults; none of the reviewed studies focused on older adults. A recent review by the IMS Institute for Healthcare Informatics1 reported on a whole range of health care apps, some of which related to pain management in the adult population, but none specific to older adults. For example, the WebMD pain coach is an app that provides a holistic approach to balancing lifestyle with chronic pain conditions. WebMD is designed as a mobile companion, allowing patients to be in control of their lifestyle choices and to review personal patterns to understand triggers, set goals, and easily share progress with health care staff. The only other pain-related app reviewed within this report was Zimmer Arthritis 411, which is a patient education resource for people who suffer from arthritis. It is designed to be used either by the patient or in conjunction with the clinician during consultation. These have not been further reviewed or validated so it is not possible to report on their effectiveness in improving pain management in older adults. Clinical Dashboards
A clinical dashboard is a tool that aims to provide clinicians with relevant information. They provide clinicians with quick and easy access to health care data that are being captured locally, along with information to help them make clinical decisions, such as best practice advice. Anderson and colleagues21 evaluated the impact of a clinical dashboard for opioid analgesic management on opioid prescribing and adherence to opioid practice guidelines in primary care. They evaluated electronic health record data from patients receiving chronic opioid therapy. After implementation of the dashboard, there was an increased adherence to certain opioid practice guidelines, including rate of urine drug testing, signing an opioid treatment agreement, conducting assessment of pain-related functional status, and having at least one visit with a behavioral health provider. There was also some evidence of a decline in chronic opioid therapy. Internet-Based Interventions
A recent review by Bender and colleagues22 examined articles published between 1990 and 2010 that evaluated evidence for Internet-based interventions for individuals with chronic pain. The review found that the interventions consisted mainly of (1) cognitive behavioral therapy (CBT), (2) moderated peer-support programs, or (3) clinical support interventions. The Internet CBT interventions were predominantly structured, self-administered programs that provided minimal support from health care staff. Peer support programs were those that allowed people with similar symptoms to exchange experiences and use a network of support. Whereas clinical support interventions were those that, for example, allowed the patient to access educational Web sites to prepare for doctor visits and provide self-management advice afterward. Most CBT interventions for pain management demonstrated an improvement in pain, improved function, and decreased costs compared with standard care. However, the effects on depression and anxiety were less consistent, which may be due to the lack of person contact. The online peer-support network evidence showed a significant reduction in the prevalence of pain and anxiety, and reduced loneliness and withdrawn behavior. Finally, clinical support interventions helped to significantly reduce pain and improved patient’s knowledge. Although this evidence was interesting, there was no specific focus on older adults, with most of the evidence focusing on children and young adults.
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Text Messaging
There is currently limited evidence regarding the effectiveness of text messaging for pain management and nothing specific to older adults. Recent evidence published in 201523 examined the preliminary effectiveness of a text message–based social support intervention for adults that aimed to reduce daily pain and pain interference, improve affect and perceptions of social support in patients with chronic noncancer pain, and explore the feasibility of a novel mobile app to track perceptions of pain and pain interference. Results found modest reductions in pain in those who received the text messages. Although this study was not specific to older adults, it did include older adults within the sample and provides some support for the feasibility of such methods in improving patients’ daily experience of pain. A recent review summarizes existing evidence regarding the compliance, feasibility, user-friendliness, reliability, and validity of text messaging in pain patients.10 Text messages could be an inexpensive way for communication between patients and health care professionals for chronic pain management. Further, this method could be easily integrated into mobiles or smartphones, which most of the population own. CHALLENGES WITH TECHNOLOGY Challenges for Health Care Staff Using Technology for Pain Management
The recent evaluation of the iPhone pain assessment app by Docking and colleagues,17 previously described, uncovered a range of challenges that health care professionals might face when using technology in the clinical setting. These challenges are detailed briefly in the following section. Appropriateness of Technology in the Clinical Setting
There are questions around the appropriateness of using technology within the clinical setting and the lack of adequate support for clinical staff to allow them the opportunity to use app-based methods in practice. In the evaluation of the iPhone pain app, most participants did not think that use of an electronic device was currently feasible in the clinical setting. This was predominantly due to their worries over perceptions of patients while using such devices. Suggestions to address this barrier include using current electronic systems in which the app could be incorporated, and changing the way in which clinicians work and record data to a more electronic-based method. All participants were in agreement that as the technology age advances there will be an increased need for technology in the clinical setting that will bring with it greater acceptance and understanding from patients of the benefit such methods can bring. Cost
There is a clear need for a cost analysis regarding the effectiveness of technologybased interventions. Taking into account the development and maintenance costs, savings across the health care system must be demonstrated and there is currently a lack of cost-analysis studies to show this outcome. Health care systems have recently made a move toward the use of electronic health records. Therefore, it might be feasible to allow for an integration of mobile appgenerated data into these systems, which could potentially reduce costs. However, this will require a huge amount of collaboration between stakeholders to allow for a smooth transition into a new technology-led health care system.
Emerging Technologies in Geriatric Pain Management
Infrastructure
The infrastructure required for a move toward technology does not currently exist from both a health care and a patient perspective. There are serious concerns around data privacy and security when using such methods. It is therefore essential that it is clear how data within apps will be used, ensuring patient consent is provided, and that the information held is secure, particularly if there is integration with electronic health records and health-related apps. With the potential for confidential patient information to be passed between systems, it is essential this is done in a secure manner and, currently, there is no infrastructure to support that. Technical Support
Current apps are not yet compatible with hospital-based electronic medical records and, as a result, there will be issues with data transfer. It is unclear who would have the responsibility to provide technical support for apps: medical informaticians, app providers, or both. Although apps should save time and money and reduce face-toface visits, there could be additional costs if technical problems occur and regularly persist. Hygiene
When using apps in the clinical setting, it is essential to be aware of the spread of infections. If tools, such as tablets, are used for pain assessment and management in a clinic, it is important that these are given suitable covers that can be regularly cleaned if they are used across patients. Challenges for Patients Using Technology for Pain Management
There is currently limited evidence to help patients understand the apps that are currently available and which apps might be most useful in assisting patients with the task of self-managing pain. This is a particular challenge for older adults who may have limited online experience and be less able to research the evidence base for health-related apps. Older adults may also not feel comfortable using certain software, and there may be challenges around reading, language, or cognitive skills.9 In the UK, the NHS developed and launched a library of NHS-reviewed apps (in 2013) aimed at empowering people to manage their own health. The NHS reviewed apps available on the market to provide consumers with evidence of which apps were clinically safe and reliable. With increasing health care costs and limited funding, the library was designed to encourage patients to be active participants in how their health is managed. Although this Web site was a step in the right direction, it did not answer all the concerns around the use of apps in health care, particularly in relation to security of patient information. The library has now been closed after coming to the end of a period of testing. However, there are plans to conduct an evaluation, glean any lessons that can be learned from this initiative, and help to inform the development of something similar in the future. Concerns over the safety and security of patient information, however, have been raised. A recent study24 found that many of the apps that were recommended failed to provide adequate protection of patient data. The investigators reported that out of 35 apps in the library that sent identifying information over the Internet, 23 did so without encryption. Therefore, although such a library would be welcomed, steps need to be taken to address these concerns and make changes where needed.
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SUMMARY
Technology has the potential to play an instrumental role in serving patients by making health care more affordable, accessible, and available. Although the future role of technology in the management of pain in the older population is promising, there are clearly current challenges that need to be addressed before technology can be fully integrated into the health care system. mHealth might provide us with the opportunity to collect clinical, patient lifestyle, and behavior data, which could improve communication between the patient and the health care provider, and may also aid in the assessment of pain within the clinical setting. However, few technologies currently exist to meet the needs of older people with chronic pain. In addition, there is limited evidence that the technology leads to improved patient outcomes or reduces use of health care services.10 Further work is needed to look into the impact of apps on hospital and clinic visits before additional money is spent developing and testing new innovations, as well as to clarify whether technology can ultimately contribute to a reduction in the burden of chronic pain. With further evidence and input from health care professionals and patients on what they actually need from emerging technologies, it might be possible to take advantage of what the technology age has to offer, to develop and use tools that can potentially improve the quality of life for older adults living with pain, and to ensure they can remain living independently and within their own homes for as long as possible. Author’s key recommendations With currently limited technologies that meet the needs of older people with chronic pain and questions around improved outcomes from technology, there is currently not enough evidence to recommend that health care professionals make use of current pain apps. However, as technology develops within this field, health care professionals should remain up to date on evidence as it emerges. The recently closed NHS library of NHS-reviewed apps is potentially going to reopen following its initial pilot testing phase. If this does happen, this would be an ideal place for health care professionals to start if interested in using apps within their practice, to identify the most useful and well-evaluated apps available for pain management. REFERENCES
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Emerging Technologies in Geriatric Pain Management
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